And often, like on this particular Monday at a Maryland conference center, most of his students are physicians and nurses. Stretched out on orange and green yoga mats for a weekend-long workshop, the 30 students learned breathing techniques, lifestyle suggestions and the research that supports the health benefits of yoga.

Narayanan, a long time practitioner and economist by day, is one of the founders of , a nonprofit organization that seeks to educate people on the benefits of this ancient Indian practice. A major part of this effort, however, is directed at integrating yoga therapy in the mainstream health care system by  to use yogic breathing and techniques to treat various maladies.

“We need to expand the horizons of physicians – yoga is much more than just relaxation response,” he said.

Since starting this push in 2010, Life in Yoga has trained 145 doctors, and its programs are recognized by the . Yoga therapy is a relatively new addition to the spectrum of courses, but one that has been proven helpful to physicians, said Dr. Murray Kopelow, president and CEO of the accreditation council.

“These are things our professionals need to know,” he said.

Dr. Harminder Kaur, a physician in Clarksburg, Md., agreed.

Kaur, who also practices yoga in her personal life, said the Life in Yoga curriculum has helped her patients with illnesses such as sleep apnea and arthritis.

“It takes one case to be successfully treated, then your mind is open to it.” she said.

Naryanan from Life in Yoga makes weekly visits to her practice to focus on specific techniques geared toward certain problems. They are currently working on ways to use yoga therapy to help patients with hypertension.

For Narayanan, the ability to home in on a specific disease and have evidence of a proven outcome is the crux of his work with health care providers. He said psychiatrists often see the most powerful results of the practice – sometimes replacing a high dose of psychotropic drugs with breathing exercises.

But to make an impact on the health care system, Narayanan wants to dispel the popular image of yoga as just an exercise or good stretch and focus on its scientific side. And he and his partners forego any salary or compensation to make sure that happens.

“Yoga is being misrepresented,” he said. “If thinking doesn’t change, if it’s not useful in a doctors’ practice, it cannot work.”

At the Maryland workshop in February, Narayanan and the team of physician instructors asked the doctors and nurses in attendance to try out some techniques to share with their patients.

And at the end of the course, the students – a group that included cardiologists, psychiatrists and physicians assistants — stood up to speak about their experiences over the weekend. Almost every person used the word inspired.

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These days a different kind of battle is being waged in this coal mining county and its neighbor, McDowell, against dangerously high rates of disease, drug abuse and early mortality.

In Mingo County, 23 percent of the population lives under the poverty line, $11,670 for individuals and $23,850 for a family of four. In McDowell, 34 percent live below the poverty line, compared with 15 percent nationally. Both counties in the lowest one percent of the nation’s counties for life expectancy.

Some of the area’s health care needs are expected to be met by increased access to insurance under the federal health law. Medicaid eligibility is being expanded, and for many individuals buying policies on the state’s insurance website there will be federal subsidies.

But having watched their friends and family suffer, some local residents have taken matters into their own hands.

For years, Williamson Mayor Darrin McCormick watched his town, Mingo’s county seat, rank low on every determinant of good health. Diabetes and obesity are nearly triple the U.S. rate. Premature death is at least 40 percent than the national benchmark, according to the Robert Wood Johnson Foundation. And 17 percent of the population is uninsured, compared with 11 percent nationally.

McCormick, a jovial, enthusiastic man, said he was frustrated and embarrassed and determined to find a way out.

That’s how “Sustainable Williamson” was born in 2010. The project combined ideas and initiatives from local officials, community members, nonprofit organizations like the Diabetes Coalition and faith groups to address both the economy and the well-being of a community where unemployment and drug use were climbing.

Hundreds of residents now gather for 5K races, and running and walking clubs have cropped up in this small town on the Tug River, marked by narrow downtown streets, charming red brick buildings and neighborhood barber shops and pharmacies where customers are greeted by name. A community garden grows alongside an old train track, and three greenhouses have been built next it. A weekend farmers’ market brings fresh produce to a town where fresh fruits and vegetables are often in short supply.

Local primary care physician Donovan Beckett and Timothy McNamee, a small business owner in Williamson, are working to open the area’s first federally funded primary care center. The centers receive government dollars to provide care for underserved populations.

But improving residents’ health will take more than money, said McCormick. “This is a more grassroots movement.”

In neighboring McDowell County, some residents are worried there is no way out.

“There are probably more people on drugs than not — you go down the road, you worry someone’s going to hit you,” said Kasondra Ramsey, an after-school teacher who lives in War, a town in the southern part of McDowell County.

But local organizations are hoping to turn things around, even if success means making sure things just don’t get any worse.

“We don’t expect someone to come riding in on a great white horse and solve everything,” said Kathie Whitt, director of Families, Agencies, Children Enhancing Services, a McDowell County nonprofit.

Her organization ran a breast cancer awareness campaign with funds from the Susan G. Komen Foundation that led hundreds to get tested. In addition, the Tug River Health Association has held screenings and preventive care clinics, and grocery stores have started to promote healthier snacks.

Local initiatives to address the counties’ health care issues are more useful than outside interventions, according to Richard Crespo, professor of community health at Marshall University in Huntington, W.Va. Crespo said Appalachian culture places a lot of emphasis on “clan” networks; people are more likely to trust people they know.

For Vicki Hatfield (yes, those Hatfields), a nurse practitioner and head of the Diabetes Coalition clinical team in Mingo County, personal familiarity with the community has made a difference in her work.

Hatfield and her team visit patients’ homes and assess data, from behavior to blood sugar levels. She said home visits reveal personal problems — how patients might run out of food stamps at the end of the month, or whether an abusive boyfriend is living off a working mother’s salary. Being local helps get her in the door.

“The most important thing is to meet people where they are,” she said.

Measuring the impact of community initiatives can be difficult — especially when they are multifaceted, like Sustainable Williamson, Crespo said. It might take years to move the needle on early death rates or drug use. But that doesn’t mean change isn’t happening.

“The most critical indicator of success to me is the number of community partnerships,” he said.

And for the volunteers, nurses, social workers and community members hoping to change the dismal health outcomes that overshadow their hometowns, every step forward is worth counting.

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Ronald Washington warmed up at a long wooden table. The 58-year-old security guard, wearing a striped winter hat and brown jacket, came during his lunch break for one of the free meals that the faith-based mission provides.

He has to stretch his salary of about $950 a month, and worries that with his high blood pressure, thyroid and eye problems, he won’t be able to afford the $150 cost of medicine. Washington was hopeful that the state’s decision to expand Medicaid would help him get covered.

Under the Affordable Care Act, states have the option to increase eligibility for Medicaid, a state-federal insurance program for low-income people. Now an individual who earns up to 138 percent of the federal poverty line, or $16,105, can qualify. Many Republican governors refused to expand the program, but West Virginia Gov. Earl Ray Tomblin, a Democrat, persuaded a divided legislature to go along.

More than 75,000 people have enrolled so far, exceeding the state’s projection of 63,000. Some advocates for the poor are thrilled, but they caution that insurance coverage alone won’t overcome the deeply rooted health problems of many poor West Virginians who live in isolation and poverty.

“If your premise is that Medicaid expansion will make a community healthier, it’s wrong. You have to look at the culture,” said Donald Reed, a program coordinator for McDowell County’s West Virginia University Extension, which brings some of the university’s resources to the area.

McDowell and adjacent Mingo County, where Washington lives, are among the poorest in the state and share problems common to other impoverished areas of the U.S.

In Mingo – where Williamson is located – 17 percent of the population is uninsured, compared to 11 percent nationally. Almost one-third of the adult population is obese, and the rate of physical inactivity is almost double the rest of the country, to the Robert Wood Johnson Foundation.

McDowell ranks even lower when it comes to health. It has the highest rate of prescription drug abuse in the country; a 33 percent obesity rate; and early death from drugs and other illness has become increasingly common. Both counties the one percent of U.S. counties with the shortest life expectancies.

For anything other than very basic health care, people have to travel, sometimes far. “They can’t even fix a broken bone here,” said Mary Anne Dudley, a McDowell resident.

Dudley, 30, who has Medicaid, said she has driven to Bluefield, W.Va., about an hour and a half away from her hometown of Coalwood, to see a doctor for an asthma attack and during her first pregnancy.

There are two federally funded health centers in McDowell County, mostly staffed by nurses and physicians’ assistants – and one community hospital. But specialized care and mental health care are not easily available, Reed said. Mingo County also has one hospital and will soon have a new federally funded health center, but patients often travel across the border to Kentucky to receive care.

Reed said the isolation of McDowell’s communities is one of the reasons government insurance cards aren’t all that’s needed. “Access,” he said, “does no good unless you can get somewhere.”

Still, Medicaid is an essential part of improving care, said Dr. James Becker, who helped the state to expand Medicaid and is now a professor at the Marshall University Joan C. Edwards School of Medicine in Huntington. “It will do a great deal to make sure they have preventive care,” he said.

To reach those likely eligible for Medicaid, the state health department sent letters to 118,000 people who receive food stamps from the Supplemental Nutrition Assistance Program. This brought in the majority of applications, while local health departments, in-person insurance assisters and the state’s online exchange, which is a partnership with the federal Department of Health and Human Services, accounted for the rest.

The state is also expanding insurance coverage by helping people who don’t qualify for Medicaid to seek private insurance with a federal subsidy through the website.

“West Virginia has, and is, making a big, big difference,” said Sister Janet Peterworth, who works with the West Virginia Healthy Kids and Families Coalition and is funded by a state government grant to help people enroll in insurance plans.

She has been driving her white Ford Escape across five counties since October to assist consumers. She picks places like busy libraries and pharmacies to reach the most people.

In early December, Peterworth parked her briefcase and sign-up forms on a table at the Williamson Housing Authority, which helps low-income individuals and families find affordable housing. An uninsured woman, Pat Blackman, who lives in a nearby subsidized housing community, showed up in the first few minutes.

The first step was to total Blackman’s household income. Her disabled husband receives a monthly check from the state. Blackman provides home help to the elderly. Together they make about $22,000 a year – just a few dollars too much for Medicaid. The for a household of two is $21,707.

Blackman, 60, said maintaining her health without insurance has been tough. Her prescriptions for medication for high blood pressure and stomach acidity would cost over $300 a month if she filled them regularly, which she couldn’t afford to do.

“Some doctors and pharmacists will work with you,” she said, “but sometimes you get turned away.”

Peterworth gave Blackman instructions on checking options through the federal website and assured her she would qualify for a subsidy and find an affordable plan.

For Washington, the success of the new program is crucial to staying healthy.

As he finished his soup and vanilla cookies at Jacobs Well, Washington said Medicaid coverage would offer him relief in the daily struggle of working to pay rent, gas and finding time to see his son, who lives in a different city.

“Most of this health stuff is caused by stress,” he said. With insurance, Washington saw a way out. “It’s about peace of mind.”

A month later, he was approved for Medicaid.

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The by the Department of Health and Human Services. It amends privacy rules under the Health Insurance Portability and Accountability Act (HIPAA) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) that required patients to get their lab results from their physician, according to the announcement.

The final rule notes that some labs and physicians had raised concerns about the move when the administration issued a preliminary rule in June 2011. “Commenters expressed concern that patients might receive and act upon results that appear to be abnormal (showing false positives or false negatives, or results that are out of the normal range for the general population) but may be normal for that particular patient due to his or her medical conditions.”

But HHS said the rule helps ensure patients have full access to their health information and can be proactive in their choices for care. The rule also notes that studies have found “physician practices failed to inform patients of abnormal test results about seven percent of the time, resulting in a substantial number of patients not being informed by their providers of clinically significant tests results.”

Dr. Jon Cohen, senior vice president and chief medical officer at Quest Diagnostics, welcomed the change. “I think more physicians are comfortable with having their patients access this information – the conversations between patients and doctors will be more substantive,” he said.

He said Quest, the largest diagnostic laboratory system in the country, believes the rule will help reduce medical errors and duplicate tests, since patients will have quicker access to this part of their medical history.

Jessie Gruman, president of nonprofit patient advocacy organization Center for Advancing Health, said the rule eliminates only one small part of a larger barrier to patients receiving information they need to make better decisions about their health and treatment. She said there is a need for more transparency about drugs and medical device costs.

“It’s certainly welcome,” she said, “but this is not a big, heroic change in policy.”

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Tigist Seyoum, a sturdy 35-year-old woman with a large black purse and corn-rowed braids, leans down to kiss the boy’s cheek as she enters. The community health worker and the boy’s mother sit on a sofa in the Girmas’ home — two tidy, small rooms crammed with furniture. They chat about neighborhood gossip and the family’s health, including checking on birth control prescriptions.

Community health workers like Seyoum have helped Ethiopia reduce child mortality by two thirds since 1990 and death from malaria, a common disease, by 55 percent. Since their deployment, contraception use among women — from longer-lasting injections to daily birth control pills — has doubled from 15 percent to almost 30 percent in six years.

More than 8,000 miles away in Williamson, W. Va., 34-year-old Samantha Runyon visits about 15 homes a week to check blood sugar levels and teach people with diabetes how to deliver insulin injections.

The nurse, who works in the rural coal mining town where she grew up, is part of a team of four other “patient navigators” at a local nonprofit, the Diabetes Coalition. Her role is funded by a Duke University research grant aimed at curbing and treating diabetes.

“You’ve got more time with them,” she said. “In an office you’re on a set schedule, but here I don’t try to rush anyone.” 

Across the world, countries have started to embrace community health workers as a means of reaching people who don’t always have regular access to care through clinics and hospitals. 

Their titles vary — India has more than 800,000 “Accredited Social Health Activists” and Malawi employs 11,000 Health Extension Workers — but the impact seems to be universal. Not only do the workers treat and manage care, they also help curb health care costs by preventing complicated disease and emergency room visits.

Their success depends partly on local connections.

“The area where community health workers catch on is where they retain their community identity and their advocacy for their community and yet have a sharply defined role in their health care system,” said Columbia University’s Dr. Prabhjot Singh, chairman of the One Million Health Worker Campaign.

In Ethiopia, community health workers like Seyoum have become an integral part of the tiered national health care system put in place in 2004 to reach mostly rural families vulnerable to disease, hunger and isolation.  The country’s Ministry of Health employs 38,000 health extension workers — an all-women workforce of mostly high school graduates with one year of health training.

There are also about 38,000 community health workers in the U.S.,  to the Department of Labor, but their role is more loosely defined. There is no uniform training or accreditation process, and their responsibilities vary by state. The Affordable Care Act includes a section recognizing the need for community health workers, but no decisions were made about their funding, said Dr. Nell Brownstein from the Centers for Disease Control and Prevention’s Division for Heart Disease.

Nevertheless, she said there is a big push from the both the health care system and states to build the workforce. Empirical research has continued to document their effectiveness — a 2009 by the American Public Health Association, for example, found that community health workers’ intervention in the care of underserved men in Denver saved $2.28 for each dollar spent by redirecting people who would normally go to hospitals for care.

Florida and Texas have thousands of community health workers that help manage chronic disease and educate communities. Massachusetts and Minnesota have led the way in legislation to define their role in the health care system.

“It’s from the community up,” Brownstein said. “There’s a considerable amount of work being done.”

Meanwhile, many American communities still struggle with threadbare health systems that could benefit from an infusion of community health workers.

Until the 1950s, the town of War, W. Va., thrived on coal production — an industry that kept movie theaters full on Wednesday evenings and powered the local economy.  As mining declined, towns like War sank into depression.  Now the main street is marked by empty windows and a chipped sign for the abandoned jail. Residents are resigned to traveling at least an hour and a half to cities like Bluefield and the state capital of Charleston for medical care.

The burden of isolation and unemployment has taken a toll on families in the area, said Tiller, pointing to black and white photos of the town in more prosperous times. In today’s McDowell County, premature death rates are more than triple the national rate. Rampant prescription drug abuse has forced children of addicted parents into foster care. And around 30 percent of the population is obese. 

“People are angry, but they don’t know who they should be angry at,” said Annetta Tiller, who works as a health liaison for Big Creek People In Action, a local organization focused on health and education.

Tiller, 37, is not immune to the local health system’s shortcomings. When she was diagnosed with colon cancer in 2007, she started to receive care from an oncologist in Bluefield, almost two hours away. Every week she would drive with her husband to receive chemotherapy, returning with her arm hooked up to a pump and bag of medicine, usually nauseated.

Columbia University’s Singh said isolated areas are ideal for the kind of services that community health care workers provide. And the lessons from reaching these areas in sub-Saharan Africa could be applied in the U.S.

In Ethiopia about 34,000 of the workers are recruited in rural areas where hospitals and clinics also can be hard to reach, according to the U.S. Agency for International Development.

Tadesech Senbu, a community health worker, works in Gora Kataba, a bucolic area about two hours outside of Addis Ababa, where goats roam the road and many older women wear traditional long skirts and wrap cotton shawls around their heads.

Senbu, a slight 23-year-old, and her colleague have a goal of reaching 500 families each in the area, where she grew up. They are trained to perform a host of specific health care duties, including administering birth control injections and delivering babies. For anything more complicated or not covered by the one-year curriculum, they are instructed to refer patients to regional health clinics, staffed by nurses and doctors.

To communicate their message, Senbu said she holds coffee ceremonies — an Ethiopian tradition — to bring people together to discuss health issues, like keeping farm animals out of living spaces and ways to space pregnancies further apart for family planning.

“We have to bring behavioral change,” she said. “I’m trying to reach them and work on prevention.”

Seyoum, in Addis Ababa, said her work is driven by the sense of responsibility she feels for her community.

That work is not easy — she visits at least 60 homes per day, armed with notebooks of data and basic medicines. But with families like the Girmas turning into models for the change she hopes to see in Ethiopia, she is optimistic about the future.

“The next generation will benefit,” she said. “There will be a big difference.”

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1. If you choose to delay, the law will make you pay. Unless, of course, your insurer canceled your plan because it didn’t meet new standards – awkward.

You have until March 31 to sign up for health insurance or pay the penalty: $95, or 1 percent of your income based on your income tax return, whichever is greater in 2014 (that goes way up by 2016: $695, or 2.5 percent of income). There are some exceptions – like if your plan was one of the thousands canceled last year in a big healthcare.gov oopsie.

2. Your employer’s health plan could change, but not necessarily.

If you get insurance through a large employer, the health law is unlikely to affect your plan, although your employer is allowed to change the plan. The law also made a few changes to workplace insurance: Plans generally lifetime coverage limits and include a that an adult child (yes, there is such a thing) up to age 26 can stay on his or her parents’ health plan. Some small employers are asking their workers to get insurance through health exchanges.

3. There’s something called a grandfathered plan, and like your Papa Joe, it kinda does whatever it wants.

Some existing plans, if they haven’t changed significantly since the law passed, . These “grandfathered plans,” for example, can still charge co-pays for preventive services, which the health law otherwise requires to be free. If you have one of these plans and your employer makes changes that raise your out-of-pocket costs, the plan would then lose its grandfathered status and all the ACA’s protections would kick in.

4. Unlike your boo, insurance companies can no longer care that you’re complicated.

Insurers can no longer deny you coverage, charge you more based on a pre-existing medical condition or limit the coverage of , which include prescription drugs and hospitalization. They also can’t kick you off the plan just because you got sick.

5. Time is the only thing you will spend for some screenings and tests.

You are likely eligible for some such as breast cancer screenings and cholesterol tests with no out-of-pocket costs to you. Hugs, however, aren’t included.

6. There’s such a thing as not broke enough. And it determines what kind of coverage you get from the government.

If you live in one of the 25 states and the District of Columbia that expanded Medicaid, the government is offering to fully cover insurance costs for anyone making less than about $16,000 for an individual and $32,500 for a family of four. If you make too much money for Medicaid, you still qualify for a subsidy through the insurance marketplaces. Those are available, for example, to people making $11,490-$45,960 per year.

7. If your company has 50 or more people, you will eventually have to provide coverage to your employees, or pay a fee.

Starting in 2015, businesses with 50 or more full-time employees . Firms with won’t face any penalties, however, and if you own a small business or start-up, the health law offers a tax credit to help cover the cost.

8. What do the health law and Miley Cyrus have in common? They had a rough 2013. But there’s some hope now that HealthCare.gov is twerking, er, working.

The Oct. 1 launch of healthcare.gov frustrated millions of consumers and gave Republicans on Capitol Hill plenty of ammunition. Then President Barack Obama had to apologize for a promise that turned out to be one he couldn’t keep when millions of Americans who buy coverage on the individual market began to learn that their current health plans were being canceled. With all that making headlines, some Americans were still having difficulty in late December trying to sign up for coverage to begin Jan. 1, so to let people who enrolled by Dec. 24 to pay as late as Jan. 10 and beyond. Officials say more than 2.2 million people have successfully enrolled in health law plans.

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Seventeen percent of people potentially eligible for coverage visited the marketplaces when they opened in October, according to a . That encompasses people going to both the finicky healthcare.gov run by the federal government for 36 states and those who went to the marketplaces run by 14 states and the District of Columbia. By the end of December — after government officials announced a fix to some of the website glitches — that number had risen to 24 percent.

Among the shoppers visiting the marketplace, researchers were surprised to find that people aged 19 to 34 comprised 41 percent of the total visitors. These “young invincibles,” as they have been dubbed, are the youthful and often healthy people needed to help hold down insurers’ overall health care costs.

“It’s a striking finding,” said , lead author and vice president for the Health Care Coverage and Access program at The Commonwealth Fund. “That’s good news for the health of risk pools.”

The survey also found that 77 percent of adults who visited the marketplaces said they were in excellent, very good, or good health.

The number of visitors who actually enrolled in a plan is yet to be determined, and only about 38 percent of visitors said they ended up applying for health insurance, according to the survey of a nationally representative sample of 622 adults who are potentially eligible for the law’s new coverage option. The survey has a margin of error of plus or minus 4.65 percent.

But the survey suggests room for improvement. While logging into the federal website has become much easier, more people in December found it difficult to determine their out-of-pocket costs than in October.

More than a third of the adults who visited the marketplaces also said it was either somewhat difficult or very difficult to figure out whether they were eligible for financial assistance or Medicaid. This could impact the low-income families who Collins said are most vulnerable to remaining uninsured or missing a deadline.

“People who have lower incomes often have very busy, busy lives,” she said. “It will be continue to be important to make sure people are aware they are eligible for significant subsidies and Medicaid.”

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But now, the 57-year-old San Francisco Bay Area resident is less sure that Obamacare will live up to his expectations. 

He plans to enroll in coverage through the state’s insurance marketplace — but he still doesn’t know if his doctors will be included.  And although he will get help with premiums and medications through an existing program for HIV patients, Sharp worries he won’t be able to afford co-payments and other out-of-pocket expenses.

“I am apprehensive,” said Sharp, a former classical dancer. “There is a lot of unease with the whole rollout. But when you are talking about a person in my situation, there is even more unease.”

The Affordable Care Act provides an unprecedented opportunity to reach the more than 1 million people nationwide living with HIV. The law requires private insurers to cover them and others with pre-existing conditions and bars companies from charging patients more because of their illness.

HIV-positive patients can also buy coverage through insurance marketplaces, often with the help of federal subsidies. And the law allows states to expand their Medicaid programs to cover low-income HIV patients who were not previously eligible.

Advocates and doctors agree that the changes will help a population that has struggled for decades to maintain regular access to care. New insurance options also could lead to more preventive care and earlier diagnosis and treatment, they said.

But they worry that the transition— along with confusion and unexpected costs— could lead to gaps in care for HIV patients, causing their illness to progress and be spread to others.

“Having an insurance card alone isn’t a guarantee that people will get high-quality HIV care,” said Jen Kates, who directs HIV policy for the Kaiser Family Foundation and helped put together about the health law for HIV patients. (Kaiser Health News is an editorially independent part of the foundation.) “There are ongoing questions: Will people be able to see the doctors they need to see? Will all the benefits they need be covered?”

Advocacy groups have criticized some health plans in the insurance exchanges for failing to cover key HIV medications, charging high amounts for necessary drugs or failing to tell consumers which doctors and medications are included.

Last month, a coalition detailed the problems in a letter to Health and Human Services Secretary Kathleen Sebelius.  It cited several examples of health insurers requiring consumers to pay a large percentage of the cost for preferred HIV medications and expressed concern that insurers were trying to discourage people with HIV from enrolling in their plans.

“In the long run, this is a move forward for people with HIV,” said Anne Donnelly, director of health care policy for Project Inform, an HIV and Hepatitis C advocacy organization in the San Francisco Bay Area. “In the short run, this is going to be a rough road.”

Only about a third of U.S. residents living with HIV now receive regular medical care. HIV patients receive coverage through work, private insurance plans or government programs such as Medicare and Medicaid. In the past, to qualify for Medicaid in most states, HIV-positive patients had to be sick enough to be deemed disabled.

Lower income HIV-positive patients now often rely on the Ryan White HIV/AIDS Program, which helps pay for primary care, support services and medications. The $2 billion program provides services to about a half million people each year. But as many of these patients become eligible for new insurance options under the health law, advocates fear Ryan White funding could be reduced or fall away.

John Hogan, a doctor who has worked with HIV-positive patients in the Washington D.C. area since 1993, said the Ryan White program is still needed, including for some who are gaining new coverage. The funding will be essential in 23 states that don’t plan to expand Medicaid and for undocumented immigrants, who don’t qualify for Obamacare, experts said. 

Oscar Lopez, 34, who works in retail merchandising, is in the country illegally and was diagnosed with HIV two years ago. He has been receiving care funded by Ryan White in Pasadena, Calif. He knows he isn’t eligible for insurance under the Affordable Care Act but still is afraid the new law could cost him access to his doctors and medications.

“We need our meds, and we need to take them every day,” he said. “I am trying to stay calm and figure out what is the next step.”

Even HIV patients with insurance often turn to the Ryan White program for help.  Bradley Land, who was infected three decades ago, is covered through both Medicaid and Medicare.  He receives his medical care at Kaiser Permanente (not affiliated with Kaiser Health News)  for both HIV and a heart condition and goes to the Pasadena Public Health Department for additional Ryan White services including  therapy, dental care and  case management.

“My medical is very well-managed,” said Land, an insurance adjuster before he retired in 1993 because of his illness. “But I also need that wrap-around care that helps me live every day. In my 15 minutes with the doctor at Kaiser, I am not going to get that.”

In cities across the nation, HIV-positive patients have been attending workshops to learn more about their options and how their coverage and medical care may change under the health law. Many are trying to navigate a world of private insurance that wasn’t open to them in the past.  At the same time, advocates for HIV patients are scrambling to find enough people with expertise in both insurance and HIV to help.

Vanessa Velez, 25, infected when she was raped as a young girl, is uncertain about how the law will affect her and her family. She is covered by her husband’s insurance plan but turns to Ryan White when the coverage falls short. The two drugs she has taken in recent years each cost $800 a month and her Cigna plan has a cap of $10,000 a year.

She knows what it’s like to feel anxious when money runs short, and how weak she feels when she isn’t at her healthiest. But she said living with the illness and trying to deal with expensive medical care has taught her confidence, faith and patience.  “Everyone has something they’re going through,” she said. 

Sharp, the former dancer in California, said he, too, is anxious but thankful. “I am lucky to be able to even get any kind of insurance,” he said.

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AnkitaR@kff.org

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In an effort to raise awareness and rein in what can seem like the Wild West of health care, the  (CalPERS), the second largest benefits program in the country, and Anthem Blue Cross started a “reference pricing” initiative in 2011. The initiative involved a system to guide their enrollees to choose facilities where routine hip and knee replacement procedures cost less than $30,000.

Here’s how it works: The CalPERS program designated certain hospitals that met this cost threshold, and enrollees who chose among these facilities pay only the plan’s typical deductible and coinsurance up to the out-of-pocket maximum. Patients who opted for other in-network hospitals were responsible for regular cost sharing and “all allowed amounts exceeding the $30,000 threshold, which are not subject to an out-of-pocket maximum,” noted the report.

The results tallied savings of $2.8 million for CalPERS, and $300,000 in patients’ cost sharing, according to released Thursday by the Center for Studying Health System Change for the non-profit group National Institute for Health Care Reform.

Researchers found that patients who received “intensive communication” from CalPERS were supportive of the efforts and recognized lack of price transparency in the system. The report also said enrollees were satisfied with the level of care they received when choosing facilities that met their cost threshold.

But that information has yet to reach the larger population of health consumers, said Alwyn Casill, the director of public relations for the Center for Studying Health System Change.

“There is a tremendous need to increase public awareness of this problem,” she said. “It should matter to you as someone who is paying for health care, not just for you, but for everybody.”

While the report doesn’t completely detail CalPERS’ approach to reference pricing, Casill said there is optimism that it will be a model for other insurance plans and medical systems.  But that is further limited by the narrow focus of this initiative on just two kinds of procedures — others, like MRIs and CAT scans, are also vulnerable to wide pricing disparities.

Some experts say any real success on streamlining health care costs will include the ability for consumers to understand the issue and call for change.

“The numbers are dramatic,” said Foundation, a non-profit educational organization unaffiliated with the report. “I think you really do need to have good quality measures, good transparency. And a lot of patient education.”

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For the past few years Mari Yuan visited a doctor only when she went back to Japan to take care of her elderly parents.

Though her husband Wemin Yuan, 74, is insured through Medicare, 57-year-old Mari, who does not work or have access to health benefits through an employer, has no health coverage. Her history of breast cancer and several surgeries drove up the price of insurance for her on the individual market, making it unaffordable. And though she is healthy now, the North Carolina couple is nervous.

“To live in this country without insurance — it’s scary,” Wemin said. “Even if she takes the car out to go to the grocery, I literally worry.”

Mari’s situation isn’t uncommon among Asian Americans: , about 2.5 million, lack coverage, according to 2012 Census data. That’s 4 percentage points higher than the average for non-Hispanic whites.

Efforts to educate this population about the coverage options in the health law have proven both daunting and dramatically different than the Obama administration’s much-touted outreach to the Latino community, which is largely united by the Spanish language.

“It’s not one size fits all — you have to tailor the messages,” said Priscilla Huang, policy director with the Asian and Pacific Islander American Health Forum, a national advocacy organization based in Washington, D.C., that works to connect the population to health care.

Huang’s group and one of its partners, the Asian Pacific Community Health Organizations, a network of community health centers, have conducted surveys, trained community clinic staff and created resources they hope will help fill the gap.

But there is no easy prescription for reaching such a diverse group. Health care workers and advocates must consider dozens of languages and dialects — from Bengali to Tagalog — when communicating with the approximately 3 million Asian Americans who have trouble speaking and understanding English. In addition, their religions, cultures and socioeconomic status add complexity to the challenge of developing educational campaigns.

About 12 percent of Asian Americans also live in poverty, but numbers often vary by country of origin. Chinese and Indian Americans, for example, have higher average incomes than their Vietnamese and Bangladeshi counterparts.

°Õ³ó±ðÌý turned to language-specific Google video chats to reach the group and answer health law questions. The first one, held in , the nationality with the highest number of uninsured people, and attracted about 500 people live. The second was held , and a Chinese Google hangout is scheduled for Jan. 23, 2014.

“Elevating it to this level, to this White House initiative, is helpful to everyone,” said Maria Pastrana Lujan, who is an advisor on community engagement to the White House effort. “But the key to making this successful is (involving) the community.”

Some states — especially those with large numbers of Asian-American residents — that have opted to operate their own online health exchanges have taken steps to reach specific immigrant groups. Covered California, for example, recruited Hmong speakers, among others, for this purpose. The New York State of Health also hired workers, known as “assistors,” because of their outreach efforts and their work to engage the state’s large Korean, Chinese and other Asian populations in the enrollment process.

This kind of focus is critical, said Perry Chan, who leads the  in Montgomery County, Md.

Chan emigrated from China more than a decade ago with his mother and brother. The family didn’t have health insurance, and, because his English was spotty, Chan didn’t feel comfortable going to the doctor until his family found a Cantonese-speaking physician.

His firsthand experience has helped Chan, now 32, lead a team that provides interpreter services and translates paperwork for patients. The team also helps the Maryland health department train outreach workers, also known as navigators, who are helping guide people through the process of obtaining insurance now available as a result of the health law.

State and locally based Asian-focused initiatives like this one are often the only bridge between the community and the health law, especially for services and translations the federal government has yet to offer.

These initiatives are “just one way we are getting the word out on the Affordable Care Act to the community,” said Rebecca Lee, an advisor to the White House Initiative on Asian Americans and Pacific Islanders. She added that they are working with “with federal, state, local and community partners on multiple ways to reach out to the Asian American and Pacific Islander community, including those with limited English proficiency.”

Health and Human Services Secretary Kathleen Sebelius met with Spanish media outlets like Univision and introduced a Spanish version of the exchange website, , called CiudadoDeSalud.Gov. A limited version of it launched Oct. 1, but a more complete one – with enrollment tools – is expected to launch by the end of the month. The focus so far has been on connecting with Spanish speakers, partly because of the administration’s push to market the health law to this group, which makes up 17 percent of the U.S. population, but 29 percent of the uninsured.

Most federal and state call centers, meant to field questions and guide consumers about health care enrollment, offer help in specific languages such as Chinese and Hindi, which together are spoken by more than 3 million people in the U.S., according to the Census. But other health law materials are only available in English and Spanish.

Huang also said none of the Asian American-focused groups that applied were awarded navigator grants, which provide funding for groups whose staff members act as in-person resources for people who are shopping for insurance on the exchanges. Meanwhile, the community clinics have started to produce their own campaigns to ensure the population doesn’t get lost in the system.

She added that, since Oct. 1 — the rocky launch of the health exchanges — partner organizations have been “overwhelmed by calls and walk-ins from Asian Americans” who are trying to understand their options. Huang said her group, the Asian and Pacific Islander American Health Forum, and its partner organizations, have been testing the federal and state call centers for both the enrollment process and their language assistance. Asian Americans, like many others, have been dealing with long wait times — 20 minutes and in one case, three hours — especially for interpretation services.

“I think it’s hard to think about how Obamacare impacts them when (Asians) don’t see their communities talked about or represented,” she said.

For families like the Yuans, it’s not a language barrier but the broader confusion around the rollout of the health care law that will determine coverage. Wemin said he supported the health law and hopes that Mari can enroll in a health care plan as soon as possible.

But first, he wants to know what’s going on.

“Once the clouds dissipate and I can see what’s ahead, we will definitely be moving forward,” he said.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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